Belsomra — Medical Mutual
Insomnia
Preferred products
- Generic eszopiclone tablets
- Generic ramelteon tablets
- Generic zaleplon capsules
- Generic zolpidem immediate-release tablets
- Generic zolpidem extended-release tablets
Initial criteria
- Patient age ≥ 18 years
- Patient has tried a preferred product; OR
- An exception applies: generic doxepin 3 mg or 6 mg if patient has documented history of addiction to controlled substances; OR
- An exception applies: generic doxepin 3 mg or 6 mg tablets or Silenor in patients age ≥ 65 years; OR
- An exception applies: Edluar or Zolpimist if patient has difficulty swallowing or cannot swallow tablets; OR
- Step Therapy Exception: Approve for 1 year if patient meets ANY of the following: A. Atypical diagnosis and/or unique patient characteristics prevent use of all preferred products (documentation required); OR B. Contraindication to all preferred products (documentation required); OR C. Patient is continuing therapy with requested non-preferred product after being stable ≥ 90 days WITH: 1. ≥ 130 days of prescription claims history demonstrating ≥ 90 days use within that period AND no generic equivalent available for requested drug; OR 2. If claims history unavailable, prescriber verification that patient has been receiving requested non-preferred product for ≥ 90 days via paid claims AND no generic equivalent available.
Reauthorization criteria
- Continuation of therapy may be approved if criteria for exceptions or stability are met, with approvals provided for 1 year unless otherwise specified.
Approval duration
2 years